Research priorities in light of current trends in microsurgical training: revalidation, simulation, cross-training, and standardisation.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly citedPlastic surgery training worldwide has seen a thorough restructuring over the past decade, with the introduction of formal training curricula and work-based assessment tools. Part of this process has been the introduction of revalidation and a greater use of simulation in training delivery. Simulation is an increasingly important tool for educators because it provides a way to reduce risks to both trainees and patients, whilst facilitating improved technical proficiency. Current microsurgery training interventions are often predicated on theories of skill acquisition and development that follow a 'practice makes perfect' model. Given the changing landscape of surgical training and advances in educational theories related to skill development, research is needed to assess the potential benefits of alternative models, particularly cross-training, a model now widely used in non-medical areas with significant benefits. Furthermore, with the proliferation of microsurgery training interventions and therefore diversity in length, cost, content and models used, appropriate standardisation will be an important factor to ensure that courses deliver consistent and effective training that achieves appropriate levels of competency. Key research requirements should be gathered and used in directing further research in these areas to achieve on-going improvement of microsurgery training

Plasma and cavitation dynamics during pulsed laser microsurgery in vivo

We compare the plasma and cavitation dynamics underlying pulsed laser microsurgery in water and in fruit fly embryos (in vivo) - specifically for nanosecond pulses at 355 and 532 nm. We find two key differences. First, the plasma-formation thresholds are lower in vivo - especially at 355 nm - due to the presence of endogenous chromophores that serve as additional sources for plasma seed electrons. Second, the biological matrix constrains the growth of laser-induced cavitation bubbles. Both effects reduce the disrupted region in vivo when compared to extrapolations from measurements in water.Comment: 9 pages, 5 figure

Concurrent Segmentation and Localization for Tracking of Surgical Instruments

Real-time instrument tracking is a crucial requirement for various computer-assisted interventions. In order to overcome problems such as specular reflections and motion blur, we propose a novel method that takes advantage of the interdependency between localization and segmentation of the surgical tool. In particular, we reformulate the 2D instrument pose estimation as heatmap regression and thereby enable a concurrent, robust and near real-time regression of both tasks via deep learning. As demonstrated by our experimental results, this modeling leads to a significantly improved performance than directly regressing the tool position and allows our method to outperform the state of the art on a Retinal Microsurgery benchmark and the MICCAI EndoVis Challenge 2015.Comment: I. Laina and N. Rieke contributed equally to this work. Accepted to MICCAI 201

Transanal minimally invasive surgery for rectal lesions

Background and Objectives: Transanal minimally invasive surgery (TAMIS) has emerged as an alternative to transanal endoscopic microsurgery (TEM). The authors report their experience with TAMIS for the treatment of mid and high rectal tumors. Methods: From November 2011 through May 2016, 31 patients (21 females, 68%), with a median age of 65 years who underwent single-port TAMIS were prospectively enrolled. Mean distance from the anal verge of the rectal tumors was 9.5 cm. Seventeen patients presented with T1 cancer, 10 with large adenoma, 2 with gastrointestinal stromal tumor (GIST) and 2 with carcinoid tumor. Data concerning demographics, operative procedure and pathologic results were analyzed. Results: TAMIS was successfully completed in all cases. In 4 (13%) TAMIS was converted to standard Park’s transanal technique. Median postoperative stay was 3 days. The overall complication rate was 9.6%, including 1 urinary tract infection, 1 subcutaneous emphysema, and 1 hemorrhoidal thrombosis. TAMIS allowed an R0 resection in 96.8% of cases (30/31 cases) and a single case of local recurrence after a large adenoma resection was encountered. Conclusion: TAMIS is a safe technique, with a short learning curve for laparoscopic surgeons already proficient in single-port procedures, and provides effective oncological outcomes compared to other techniques

Ultrastructure of cytoplasmic fragments in human cleavage stage embryos

Purpose: The goal of this study was to evaluate the ultrastructure of cytoplasmic fragments along with the effect of cytoplasmic fragment and perivitelline space coarse granulation removal (cosmetic microsurgery) from embryos before embryo transfer on ART outcomes. Methods: One hundred and fifty intracytoplasmic sperm injection cycles with male factor infertility were included in this prospective study. Patients were divided into three groups of case (n = 50), sham (n = 50), and control (n = 50). Embryos with 10–50 % fragmentation were included in this study. Cosmetic microsurgery and zona assisted hatching were only performed in case and sham groups respectively. Extracted fragments were evaluated ultrastructurally by transmission electron microscopy (TEM). Rates of clinical pregnancy, live birth, miscarriage, multiple pregnancies, and congenital anomaly in the three groups were also compared. Results: Micrographs from TEM showed that mitochondria were the most abundant structures found in the fragments along with mitochondria-vesicle complexes, Golgi apparatus, primary lysosomes, and vacuoles. There were no significant differences in demographic characteristics, laboratory and clinical data, or embryo morphological features between the groups. The rate of clinical pregnancy in control, sham, and case groups had no significant differences (24, 18, and 18 %, respectively). The rates of live birth, miscarriage, multiple pregnancy, and congenital anomaly were also similar between the different groups. Conclusions: Our data demonstrated that cosmetic microsurgery on preimplantation embryos had no beneficial effect on ART outcomes in unselected groups of patients. As mitochondria are the most abundant organelles found in cytoplasmic fragments, fragment removal should be performed with more caution in embryos with moderate fragmentation

Towards an Implantable Vestibular Prosthesis: The Surgical Challenges

Published versio

The use of Bioceramics as root-end filling materials in periradicular surgery: a literature review

Introduction: Periradicular surgery involves the placement of a root-end filling following root-end resection, to provide an apical seal to the root canal system. Historically several materials have been used in order to achieve this seal. Recently a class of materials known as Bioceramics have been adopted. The aim of this article is to provide a review of the outcomes of periradicular surgery when Bioceramic root-end filling materials are used on human permanent teeth in comparison to “traditional” materials. Methods & results: An electronic literature search was performed in the databases of Web of Science, PubMed and Google Scholar, between 2006 and 2017, to collect clinical studies where Bioceramic materials were utilised as retrograde filling materials, and to compare such materials with traditional materials. In this search, 1 systematic review and 14 clinical studies were identified. Of these, 8 reported the success rates of retrograde Bioceramics, and 6 compared treatment outcomes of mineral trioxide aggregate (MTA) and traditional cements when used as root-end filling materials. Conclusion: Bioceramic root-end filling materials are shown to have success rates of 86.4–95.6% (over 1–5 years). Bioceramics has significantly higher success rates than amalgam, but they were statistically similar to intermediate restorative material (IRM) and Super ethoxybenzoic acid (Super EBA) when used as retrograde filling materials in apical surgery. However, it seems that the high success rates were not solely attributable to the type of the root-end filling materials. The surgical/microsurgical techniques and tooth prognostic factors may significantly affect treatment outcome

Postoperative care in finger replantation. Our case-load and review of the literature

OBJECTIVE: Technical success of a finger replantation depends on several factors such as surgical procedure, type of injury, number of segments amputated, amputation level and individual patient factors. Among early complications that can occur in this type of surgery the onset of venous or arterial thrombosis is the most dreaded. Local irrigating solutions, oral and intravenous anticoagulants, thrombolytic agents, plasma expanders, vasodilating, and antiaggregant drugs are routinely used in patients undergoing microvascular procedures, but currently there is only a non-standardized practice based on anecdotal personal experience. MATERIALS AND METHODS: The aim of our study is to review selected literature relating to perioperative therapy in microsurgical digital replantation. We also report our case-load of 16 patients with finger avulsion describing our particular protocol for postoperative anticoagulation and restoration of fluid and electrolyte balance. RESULTS: Following our daily pharmacological protocol, the postoperative course of the replanted fingers was uneventful. The survival rate for finger replantations performed was 100% (n = 16) with no need for surgical revisions. CONCLUSIONS: The association Dextran-40/Heparin/fluids in the proposed standardized pro-weight pharmacological protocol is an optimal postoperative prophylactic/therapeutic plan to reduce the incidence of endovascular thrombosis after replantation, so ensuring high rate of success in microvascular surgery

Transoral laser surgery for laryngeal carcinoma: has Steiner achieved a genuine paradigm shift in oncological surgery?

Transoral laser microsurgery applies to the piecemeal removal of malignant tumours of the upper aerodigestive tract using the CO2 laser under the operating microscope. This method of surgery is being increasingly popularised as a single modality treatment of choice in early laryngeal cancers (T1 and T2) and occasionally in the more advanced forms of the disease (T3 and T4), predomi- nantly within the supraglottis. Thomas Kuhn, the American physicist turned philosopher and historian of science, coined the phrase ‘paradigm shift’ in his groundbreaking book The Structure of Scientific Revolutions. He argued that the arrival of the new and often incompatible idea forms the core of a new paradigm, the birth of an entirely new way of thinking. This article discusses whether Steiner and col- leagues truly brought about a paradigm shift in oncological surgery. By rejecting the principle of en block resection and by replacing it with the belief that not only is it oncologically safe to cut through the substance of the tumour but in doing so one can actually achieve better results, Steiner was able to truly revolutionise the man- agement of laryngeal cancer. Even though within this article the repercussions of his insight are limited to the upper aerodigestive tract oncological surgery, his willingness to question other peoples’ dogma makes his contribution truly a genuine paradigm shift

Early markers of angiogenesis and ischemia during bowel conduit neovascularization

Background Bowel flaps are a good and reliable method to restore the continuity of the aerodigestive tract. Radiated fields, contaminated recipient sites, or depleted recipient vessels may increase the risk for ischemic injury after transfer. During ischemic events, we believe that bowel conduits with serosa have a delayed neovascularization process at its new recipient site. We conducted an ischemia/reperfusion murine model to understand the difference among bowel conduits with and without serosa. Materials and Methods Two groups of rats were compared: control group (jejunal conduit with serosa) and a target group (jejunal conduit without serosa). These conduits were harvested from the peritoneal cavity and transferred into a subcutaneous pocket. After 72 hours of transfer and pedicle ligation, histological changes related to ischemia/reperfusion were assessed. In addition, tissue markers of angiogenesis (CD34), ischemia (lactate dehydrogenase [LDH]), and inflammation (interleukin [IL]-1β and IL-6) were analyzed. Results Two groups (n = 20) of male rats were analyzed. Histology showed intact jejunal mucosa in the target group. The control group showed decreased number of mucin, globet cells, decreased height, and fragmentation of villi with the absence of intestinal glands. Markers of angiogenesis (CD34) were higher in the target group. In addition, markers of ischemia (LDH) (p = 0.0045) and inflammation (IL-1b, p = 0.0008, and IL-6, p = 0.0008) were significantly lower in the target group as compared with the control group. Conclusions In circumstances in which the recipient site does not offer an adequate and healthy bed or a vascular insult occurs, bowel flaps with less amount of serosa may be able to neovascularize faster thereby increasing its chances of survival